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          <h1 class="post-title" itemprop="name headline">聊聊跟楔缺相关的解剖知识——2019锐读会《牙颈部非龋性病损及牙本质过敏症》课程笔记</h1>
        

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        <p>第二部分：与NCCL和CDH相关的解剖学知识<br>第一章：与NCCL和CDH相关的牙釉质考量<br>第一节 釉质概述<br>1.覆盖整个解剖牙冠<br>2.保护牙本质和牙髓<br>3.抗磨耗和生物腐蚀<br>4.非活性组织无法再生和自我修复<br>5.可以再矿化<br>第二节 结构组成<br>1.96%重量比无机物，3%的水，1%的有机物<br>2.基本结构单位为釉柱<br>3.釉柱绕长轴有序排列<br>4.釉柱内垂直本质外层略向牙尖倾斜。<br>5.近牙尖处接近垂直近颈部平行。<br>6.釉柱之间是釉柱间质（通过连续的晶体相连形成网状结构）<br>第三节 物理特性<br>1.渗透性（釉质着色和漂白及再矿化）<br>2.厚度（牙尖处最厚2500μm窝沟和颈部最薄80μm）<br>第四节 釉牙本质界(DEJ)<br>1.釉质和本质互相渗透，具有釉质和本质的生物机械特性。<br>2.避免导致牙齿裂纹扩展<br>第五节 生物机械性能<br>1.概述<br>生物材料的机械反应——变形<br>2.弹性<br>a.材料在外部力量作用下发生变形去除外力后恢复至原始形态。<br>b.弹性模量E：材料在弹性范围内固有的强度。<br>c.比例极限：材料在弹性期向塑性期的转变点。<br>d.极限强度US：材料折裂时的强度。<br>3.硬度<br>a.指材料表面抵抗永久性压痕或抵抗穿透的性质。<br>b.部位和厚度不同硬度不同。<br>4.硬度和弹性模量的交互作用<br>a.概述：釉质机械强度与部位、化学组成、釉柱排列方式有关<br>b.硬度与弹性模量的交互：<br>厚度及部位<br>釉质排列方式<br>年龄与钙含量（矿化程度）<br>5.折裂特性和类型<br>1)折裂特性<br>a.DEJ附近釉柱相互交叉类似花篮状限制外向内裂纹的发展<br>b.起自DEJ伸向釉质的釉丛是内部应力集中的引发点。<br>c.咬合的干扰早接触点导致变形导致裂纹。<br>d.内部薄弱界面在承受剪切力时导致釉柱交界的滑动。<br>2)折裂类型<br>a.内部因素（釉质内部缺陷例如釉丛）<br>b.外部因素（坚硬集中的咬合接触点）<br>c.薄的釉质裂纹常见釉质表层到DEJ（颈部）<br>d.厚的釉质裂纹常见由DEJ到釉质表层（牙尖）<br>e.裂纹形成后拉应力垂直裂纹表面加速釉质丢失<br>颈部的釉柱：水平排列<br>颈部釉质薄<br>颈部釉质强度弱<br>颈部釉质折裂从外侧向内侧。<br>EDJ釉柱编织成丛状，限制裂纹向内扩展。<br>如果颈部釉质受到拉伸作用，折裂的釉质会崩脱出来，短时间迅速形成非常明显的缺陷，表现出深角。<br>如果颈部釉质受到压应力，釉柱会向内移动，釉质不易崩脱，破损速度较慢，表现面积偏大，颈部角偏钝。<br>第六节 临床意义<br>1.咬合早接触牙冠发生挠曲<br>2.颈部釉质薄多为无釉柱釉质<br>3.挠曲导致拉应力和剪切力釉柱易裂开<br>4.釉质本质弹性模量不同颈部挠曲出现应力集中<br>5.生物腐蚀和牙膏/牙刷促进作用<br>第二章：与NCCL和CDH相关的牙本质-牙髓复合体考量<br>第一节 牙本质牙髓复合体概述<br>a.牙本质与牙髓之间结构和发育的交互影响是维持牙齿活力和功能必要的生物学调节机制<br>b.牙髓有必要的感觉、保护、修复功能。<br>c.牙本质对内保护牙髓对外支撑釉质和骨质。<br>d.牙本质和牙髓是不可分离的所以统称为牙髓牙本质复合体<br>第二节 生物机械行为<br>a.不同位点牙本质弹性模量不同<br>b.管间牙本质和管周牙本质面积质量不同，靠近EDJ的管间牙本质面积质量大，弹性好。随着靠近髓腔，管周牙本质面积质量增大，脆性增加，抵抗挠曲变形的能力下降。<br>c.早接触的咀嚼力是周期负荷（弯钢丝原理）<br>d.老龄牙齿和硬化牙本质韧性较差（无机物增加）<br>e.牙本质小管排列与受力垂直对抗力较差<br>f.低pH下牙本质硬度降低<br>第三节 临床意义<br>a.牙本质渗透性控制刺激物的扩展速度<br>b.近髓牙本质小管数量增加韧性降低<br>c.反应性牙本质强度较低（晶体小排列不佳）易磨耗<br>d.NCCL早发现早治疗。<br>第三章：与NCCL和CDH相关的牙周组织考量<br>牙骨质已纳入牙周组织<br>第一节 牙槽骨<br>a.受压吸收<br>b.有骨吸收龈退缩考虑颈部压应力过大。<br>第二节 牙骨质<br>a.覆盖牙本质表面薄层钙化组织附着牙周膜悬吊牙龈<br>b.有一定程度的再修复和再适应能力<br>c.无血管依靠周围的血管供应<br>d.有三种覆盖形式<br>e.厚度20-50μm<br>尽量别损伤。产生楔缺尤其是陈旧楔缺，患者已经适应了咬合，一般不用调颌。<br>楔缺充填完以后敏感的原因：充填完成后使用车针修整充填体边缘，有可能把充填体下发的很薄的牙骨质去除，暴露了牙本质小管。怎么办？橡皮障暴露视野，用12D或15D刀片在放大视野下修整。<br>第三节 牙龈和牙周膜<br>a.上前牙唇侧下前牙舌侧附着龈最宽，充填楔缺没问题。<br>b.下颌前磨牙牙龈最窄（不一定必须上障）<br>第四节 临床意义<br>第三部分:NCCL和CDH病因作用机制<br>第一章 应力<br>第一节 应力<br>1.定义：是指传递到构成物体的材料内部的力形成的能量。<br>应力散失——形变<br>2.应力的分类<br>a.同一长轴反方向离心——变长<br>b.同一长轴反方向向心——变短<br>c.平行的不同平面相反方向作用——撕裂<br>3.应变的定义<br>a.受外部作用（力）后任何可导致形态或尺寸改变的几何构型变化<br>b.应变是应力的结果。<br>4.应变的分类<br>弹性应变<br>塑性应变<br>破裂应变</p>
<p>个人总结：与NCCL相关的解剖知识。釉质无机物含量高，硬度高，不能再生和自我修复能力。釉质的基本结构为釉柱，绕长轴有序排列。釉柱内垂直牙本质外层略向牙尖倾斜，近牙尖处垂直，近颈部平行。釉质的厚度不一致，在牙尖处最厚约2.5mm，在窝沟和颈部最薄80μm。釉牙本质界处釉质和本质混合，能阻止裂纹向牙本质扩展。颈部牙釉质的种种特性导致其很薄弱，容易在颈部形成折裂。当收到拉伸力时，釉质会崩脱，短时间能形成明显的深角的缺损。当釉质受到压应力时，釉柱向内移动，不易崩脱，破损速度较慢，表现为面积大的钝角缺损。牙本质保护牙髓，形成复合体。不同位点的牙本质弹性模量不同，在颈部的牙本质靠近髓腔，管周牙本质面积质量增大，脆性增加，抵抗挠曲变形的能力下降。另外还有咬合、牙齿增龄性变化，酸性作用等促进牙本质破损。牙骨质是牙周组织的一部分，有一定再生生理，很薄，无血管。临床上注意不要破坏，否则容易导致牙本质敏感。</p>
<p>最后做个广告吧，3000一年，那两场线下课就值回来了。 不过光听可能还是不行，还是要自己看书、实操的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/011/02.png"></p>
<p>我发文章的四个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的博客园博客地址： <a target="_blank" rel="noopener" href="https://www.cnblogs.com/zwdnet/">https://www.cnblogs.com/zwdnet/</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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